Professional Documents
Culture Documents
surveillance for streptococcal pharyngitis. Ideally a sore 3. Medscape (2012), Thomas K Chin, Paediatric Rheumatic Heart
and 600,000 units for children is adequate, or oral penicillin 8. Kaplan, E.L. ( 1 9 8 5 ) Int. J. Epi, 14 (4) 499.
(Penicillin V or Penicillin G) should be given for 1 0 days. 9. Strasser, T. ( 1 9 7 8 ) WHO Chronicle, 32 ( 1 ) 18-25.
This is the least expensive method of giving penicillin for 10. Wahi, P.L. (1984) Ann Acad. Med. Sci. (India) 20 (4) 199-215.
eradication of streptococci from the throat. For patients with 11. El Kholy, A. et al ( 1 9 7 8 ) . Bull WHO 5 6 : 8 8 7 .
allergy to penicillin, erythromycin is the drug of choice. The 12. WHO (2004), Tech. Rep. Ser. No. 923.
MCH and school health services should be utilized for this 13. Strasser, T. et al ( 1 9 8 1 ) Bull WHO 5 9 : 285-294.
purpose.
Secondary prevention ( i . e . , the prevention of recurrences eventual death of the affected patient if the tumour has
of RF) is a more practicable approach, especially in progressed beyond that stage when it can be successfully
developing countries. It consists in identifying those who removed. Cancer can occur at any site or tissue of the body
have had RF and giving them one intramuscular injection of and may involve any type of cells.
Objective evaluation of available data indicates that rise to 22 million annually within the next two decades. Over
penicillin alone will not lead to effective control. Predictions the same period, cancer deaths are predicted to rise from an
suggest that many of the countries which suffer severe estimated 8.2 million annually to 13 million per year.
economic constraints will not be likely to be able to raise Globally, during 2 0 1 2 , the most common cancers diagnosed
their standards of living in the foreseeable future to were those of the lung ( 1 . 8 m i l l i o n ) , breast ( 1 . 7 million) and
significantly alter the incidence of this disease (9). colorectal ( 1 . 4 m i l l i o n ) . The most common causes of cancer
mortality, Estimates for 2008. become "westernized". As such, the pattern of cancer
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incidence is likely to follow, that seen in high HDI settings, cancer in different regions of the world for men and w o m e n .
with likely decline in cancer incidence rate of cervix uteri Table 1 and 2 show the age standardized incidence and
and stomach, and increasing incidence rates . of breast, mortality of most common cancers in men and women
Large variations in both cancer frequency and case lung cancer accounts for most deaths from cancer in the
fatality are observed, even in relation to the major forms of world ·(1.6 million) annually, since it is most invariably
TABLE 1
Estimated incidence, mortality and 5-ye ar prevalence of top 1 0 cancers worldwide, 2012
MEN
Lymphoma
non-melanoma
skin cancer
!woMEN
lymphoma
non-melanoma
skin cancer
'BOTH SEXES
non-melanoma
skin cancer
* Incidence and mortality data for all ages. 5-year prevalence for adult population only.
S o u r c e : (4)
CANCER
TABLE 2
. _ · . . . . . . • ··.· ·>>World · : ·
. . - .
(thousands)
* Age-standardized rate (W): A rate is the number of new cases or deaths per 100 000 persons per year. An age-standardized rate is the rate that
a population would have if it had a standard age structure. Standardization is necessary when comparing several populations that differ with
respect to age because age has a powerful influence on the risk of cancer.
Risk of getting or dying from the disease before age 75 (%) : The probability or risk of individuals getting/dying from cancer. It is expressed as
the number of new born children (out of 100) who would be expected to develop/die from cancer before the age of 75, if they had cancer.tin the
Source : (4)
associated with poor prognosis. On the .other hand, The five most frequent cancers in men were cancer lung,
appropriate intervention is often effective in avoiding fatal lip and oral cavity, stomach, colorectum and other pharynx,
outcome following diagnosis of breast cancer. Hence this and in women, cancer breast, cervix uteri, colorectum,
particular cancer, which rank second in terms of incidence, ovary, lip and oral cavity. Cancer in males were mostly
is not among the top three causes of death from cancer, tobacco related. In women, cervical cancer is closely
which are respectively cancers of the lung, stomach, and associated with poor genital hygiene, early consummation of
distribution between the sexes are attributable to differences Facilities for screening and proper management of cancer
in exposure to causative agents rather than to variation in patients are grossly limited in India. More than two-thirds of
the susceptibility. For other tumour types, including cancers cancer patients are already in an advanced and incurable
that cancers of breast, prostate and uterine cervix are the Few decades ago, cancer was the sixth leading cause of
cause of death in only a minority of patients diagnosed (5). death in industrialized countries; today, it is the second
Cancer patterns
It is estimated that during the year 2 0 1 2 , 1 0 . 1 5 lac new
cancer cases occurred in the country, of these 4.77 lac were There are wide variations in the distribution of cancer
males and 5.37 lac females. It gives an incidence rate of throughout the world. That cancer of the stomach is very
92.4 per lac population. Same year about 6 . 8 3 lac persons common in Japan, and has a low incidence in United States.
died of cancer, (3.57 lac males and 3.26 lac females), a The cervical cancer is high in Columbia and has a low
mortality rate of 69.7 per lac population. Table 3 and 4 show incidence in Japan. In the South-East Asia Region of WHO,
the age standardized incidence and mortality due to cancer the great majority are cancers of the oral cavity and uterine
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TABLE 3
MEN
Lip and oral cavity 11.3 10.1 10.2 6.7 12.6 18.5 ·
non-melanoma
skin cancer
JwoMEN
non-melanoma
skin cancer
IBOTHSEXES
non-melanoma
skin cancer
S o u r c e : (6)
TABLE 4
Summary Statistics, I n d i a - 2 0 1 2
Risk of dying from cancer before age 75 (%) 7.8 6.5 7.1
(thousands)
Source: (5)
CANCER
pattern of cancer are attributed to multiple factors such as origin. The human T-cell leukaemia virus is associated with
environmental factors, food habits, lifestyle, genetic factors adult T-cell leukaemia/lymphoma in the United States and
or even inadequacy in detection and reporting of cases. southern parts of Japan (5, 12). (f) PARASITES : Parasitic
stages I and II. But unfortunately, in most cases, the patients related to cancer.
crux of the problem. Genetic influences have long been suspected. For
deaths (10). (c) DIETARY FACTORS: Dietary factors are also Cancer prevention· until recently was mainly concerned
related to cancer. Smoked fish is related to stomach cancer, with the early diagnosis of the disease (secondary
dietary fibre to intestinal cancer, beef consumption to bowel prevention), preferably at a precancerous stage. Advancing
These include exposure to benzene, arsenic, cadmium, (a) CONTROL OF TOBACCO AND ALCOHOL
chromium, vinyl chloride, asbestos, polycyclic hydrocarbons, CONSUMPTION : Primary prevention offers the greatest
etc. Many others remain to be identified. The risk of hope for reducing the number of tobacco-induced and
occupational exposure is considerably increased if the alcohol related cancer deaths. It has been estimated that
individuals also smoke cigarettes. Occupational exposures control of tobacco smoking alone would reduce the total
are usually reported to account for 1 to 5 per cent of all burden of cancer by over a million cancers each year ( 1 5 ) .
human cancers ( 1 1 ) . (e) VIRUSES: An intensive search for a (b) PERSONAL HYGIENE: Improvements in personal
viral origin of human cancers revealed that hepatitis B and C hygiene may lead to declines in the incidence of certain types
virus is causally related to hepatocellular carcinoma. The of cancer, e . g . , cancer cervix. (c) RADIATION: Special efforts
relative risk of Kaposi's sarcoma occurring in patients with should be made to reduce the amount of radiation (including
HIV infection is so high that it was the first manifestation of medical radiation) received by each individual to a minimum
the AIDS epidemic to be recognized. Non-Hodgkin's without reducing the benefits. (d) OCCUPATIONAL
lymphoma, a cancer of the lymph nodes and spleen is a late EXPOSURES : The occupational aspects of cancer are
complication of AIDS. The Epstein-Barr virus (EBV) is frequently neglected. Measures to protect workers from
associated with 2 human malignancies, viz. Burkitt's exposure to industrial carcinogens should be enforced in
lymphoma and nasopharyngeal carcinoma. Cytomegalovirus industries. (e) IMMUNIZATION: In the case of primary liver
(CMV) is a suspected oncogenic agent and classical Kaposi's cancer, immunization against hepatitis B virus and for
sarcoma is associated with a higher prevalence of antibodies prevention of cancer cervix immunization against HPV
to CMV. Human papilloma virus (HPV) is a chief suspect in presents an exciting prospect. (/) FOODS, DRUGS
cancer cervix. Hodgkin's disease is also believed to be of viral AND COSMETICS: These should be tested for carcinogens.
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{g) AIR POLLUTION : Control of air pollution is another of time trends, and planning and evaluation of operational
preventive measure. (h) TREATMENT OF PRECANCEROUS activities in all main areas of cancer control.
polyposis, warts, chronic gastritis, chronic cervicitis, and Cancer screening is the main weapon for early detection
adenomata is one of the cornerstones of cancer prevention. of cancer at a pre-invasive (in situ) or pre-malignant stage.
{i) LEGISLATION : Legislation has also a role in primary Effective screening programmes have been developed for
prevention. For example, legislation to control known cervical· cancer, breast cancer and oral cancer. Like primary
environmental carcinogens (e.g., tobacco, alcohol, air prevention, early diagnosis has to be conducted on a large
pollution). {j) CANCER EDUCATION : An important area of scale; however, it may be possible to increase the efficiency
primary prevention is cancer education. It should be directed of screening programmes by focussing on high-risk groups.
at "high-risk" groups. The aim of cancer education is to Clearly, there is no point in detecting cancer at an early
motivate people to seek early diagnosis and early treatment. stage unless facilities for treatment and after-care are
Cancer organizations in many countries remind the public of available. Early detection programmes will require
the early warning signs ("danger s i g n a l s " ) of cancer. These
mobilization of all available resources and development of a
are: cancer infrastructure starting at the level of primary health
a. a lump or hard area in the breast care, ending with complex cancer centres or institutions at
f. blood loss from any natural orifice or chemotherapy or both. Since most of the known methods
There is no doubt that the possibilities for primary over the world. In the developed countries today, cancer
prevention are many. Since primary prevention is directed at treatment is geared to high technology. For those who are
large population groups (e.g., high risk groups, school beyond the curable stage, the goal must be to provide pain
children, occupational groups, youth clubs), the cost can be relief. A largely neglected problem in cancer care is the
high and programmes difficult to conduct. Primary management of pain. The WHO has developed guidelines
prevention, although a hopeful approach, is still in its early on relief of cancer pain (18). "Freedom from cancer pain" is
stages. Major risk factors have been identified for a small now considered a right of cancer patients.
population will always be a selected population, the use of (a) Mass screening by comprehensive cancer detection
these registries for epidemiological purposes is thus limited. examination: A rapid clinical examination, and examination
(b) POPULATION-BASED REGISTRIES : A right step is to of one or more body sites by the physician is one of the
set up a "hospital-based cancer registry" and extend the important approaches for screening for cancer. (b) Mass
same to a "population-based cancer registry". The aim is to screening at single sites : This comprises examination of
cover the complete cancer situation in a given geographic single sites such as uterine cervix, breast or lung.
area. The optimum size of base population for a population {c) Selective s c r e e n i n g : This refers to examination of those
based cancer registry is in the range of 2-7 million ( 1 7 ) . The people thought to be at special risk, for example, parous
data from such registries alone can provide the incidence women of lower socio-economic strata upwards of 35 years
rate of cancer and serve as a useful tool for initiating of age for detection of cancer cervix, chronic smokers for
1 . Screening for cancer cervix has been concern about exposure to radiation from repeated
programmes have reduced the incidence and mortality from Although recent evidence points to the superiority of
cervical cancer in many developed countries. mammography over clinical examination in terms of
visual inspection with 5 per cent acetic acid (VIA), VIA with
3 . Screening for lung cancer
magnification (VIAM), and visual inspection post application
At present there are only two techniques for screening for
of Lugol's iodine (VIL!) are some of the alternative screening
lung cancer, viz. chest radiograph and sputum cytology.
tests, which have been studied for their effectiveness in
Mass radiography has been suggested for early diagnosis at
India. Sensitivity of VIA tends to be similar to cytology based
six monthly intervals, but the evidence in support of this is
screening. It is easy to carry out and easy to train
not convincing. So it is not recommended. It is doubtful
appropriate health workers (20).
whether the disease satisfies the criteria of suitability for
The present strategy is to screen women using visual
screening (see chapter 4 ) .
inspection after application of freshly prepared 5 per cent
acetowhitening of ulceroproliferative growth on the cervix Oral cancer is one of the ten most common cancers in the
constiute a positive VIA or VIAM. The test is followed by a world. Its high frequency in Central and South East Asian
single visit approach for further investigation and countries (e.g., India, Bangladesh, Sri Lanka, Thailand,
management at district hospital. The management at district Indonesia, Pakistan) has been well documented. It is
hospital is planned in such a way that the treatment based estimated that during the year 2012, about 1.98 lac new
on colposcopy is offered in the same visit. Pap smear and cases and 98,000 deaths occurred worldwide, with a
biopsy are the investigations that are done to ensure that mortality rate of 2 . 1 per lac population (4).
Intensive information, education and communication For the year 2 0 1 2 , with estimated incidence of 1 0 . 1 cases
activities are required to sensitize the community about the per 100,000 population for males and 4.3 per 100,000
significance of the disease and its early detection through population in females, oral cancer is a major problem in
2 . Screening for breast cancer 77,003 new cases occurred in the country with 52,067
(a) breast self-examination (BSE) by the patient (b) palpation (a) Tobacco : Approximately 90 per cent of oral cancers in
by a physician (c) thermography, and (d) mammography. South East Asia are linked to tobacco chewing and tobacco
drawbacks: ( i ) exposure to radiation. This may amount to a (b) Alcohol : Data indicates that oral cancer can also be
dose of 500 milliroentgen compared to a 30-40 caused by high concentrations of alcohol, and that alcohol
milliroentgen dose received in chest X-ray. Therefore, there appears to have a synergistic effect in tobacco users (23).
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(c) Pre-cancerous stage : The natural history of oral 2 . Cancer of the cervix
cancer shows that often a precancerous stage precedes the
This is the second most common cancer among women
development of cancer. The pre-cancerous lesions
worldwide, with an estimated 527,624 new cases and
(leukoplakia, erythroplakia) can be detected for upto
265,653 deaths with overall incidence: mortality ratio of
15 years prior to their change to an invasive carcinoma (23).
52 per cent (4). Developing countries, where it is often the
Intervention at this stage may result in regression of the
most common cancer among women, account for 88 per
lesion.
cent of cases. Wide variations in incidence and mortality
(d) High-risk g r o u p s : These include tobacco chewers and from the disease exist between countries. Cases and deaths
smokers, bidi smokers, people using tobacco in other forms have declined markedly in the last 40 years in most
such as betel quid; people who sleep with the tobacco quid industrialized countries, partly owing to a reduction in risk
to be taken into account (8). Tobacco is smoked in the form In India, cancer of the cervix is the second most common
of manufactured cigarettes. The indigenous forms of number one killer cancer among women. It is estimated that
smoking are : bidi, chutta (cigar), c h i / u m , hookah (hubble- during 2 0 1 2 , 122,644 new cases of cancer cervix occurred
bubble). Tobacco in powdered form is inhaled as snuff. in the country (incidence rate of 22 per lac population) and
and slaked lime in the palm of their left hand until the
NATURAL HISTORY
desired mixture is obtained. The mixture (khaini) is then put
(a) The disease: Cancer cervix seems to follow a
into the mouth in small amounts and at frequent intervals
progressive course from epithelial dysplasia to carcinoma in
during the day and slowly sucked and swallowed after
situ to invasive carcinoma (Fig. 1 ) . There is good evidence
dilution with saliva.
that carcinoma in situ persists for a long time, more than
Cancer of the oral cavity is also very prevalent -in
8 years on an average (19). The proportion of cases
Central Asian districts of USSR, where people chew "nass'' progressing to invasive carcinoma from preinvasive stage is
or "nasswar" - a mixture of tobacco, ashes, lime and cotton not known - it may average 15 to 20 years or longer ( 3 1 ) .
seed oil. The duration of the preinvasive stage is also not known.
Another type of cancer common in the eastern coastal There is evidence that some in situ cases will spontaneously
regions of Andhra Pradesh state in India is the epidermoid regress without treatment. Once the invasive stage is
carcinoma of the hard palate. It is associated with the habit reached, the disease spreads by direct extension into the
of reverse smoking of cigar (ch utta), i . e . , smoking with the lymph nodes and pelvic organs.
FIG. 1
a. PRIMARY PREVENTION
Hypothetical model of the natural history of cancer cervix
control of oral cancer in developing countries (30). marriage, early coitus, early childbearing and repeated
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childbirth have been associated with increasing risk. Breast cancer is not only infrequent in Indian women, but
(e) ORAL CONTRACEPTIVE PILLS : There is renewed also it occurs in them a decade earlier than in Western
concern about the possible relationship between pill use and women - the mean age of occurrence is about 42 in I n d i a ,
the development of invasive cervical cancer (33). A recent as compared to 53 in the white women.
virtually 100 per cent for carcinoma in situ, 79 per cent for the risk of breast cancer as compared with 30 years (42).
women, with an estimated 1 . 6 7 million new cases diagnosed (f) PRIOR BREAST BIOPSY : Prior breast biopsy for
in 2 0 1 2 (about 25 per cent of all cancers). It is now the most benign breast disease is associated with an increased risk of
common cancer both in developed (794,000 cases) and breast cancer.
developing regions (883,000 cases). Incidence rates vary
(g) DIET : Current aetiological hypotheses suggest that
from 27 per lac women in Eastern Africa to 98 per lac
cancer of the breast is linked with a high fat diet and obesity.
women in Western Europe. The range of mortality rate is
It is not known how dietary fat influences breast cancer risk
similar, approximately 6-20 per lac, because of the more
at a cellular level (43).
favourable survival of breast cancer cases in developed
(h) SOCIO-ECONOMIC STATUS : Breast cancer is
countries. As a result, breast cancer ranks as the fifth cause
common in higher socio-economic groups. This is explained
of death from cancer, but it is still the most frequent cause of
by the risk factor of higher age at first birth.
cancer death in women in developing regions (36).
(i) OTHERS : (i) Radiation : An increased incidence of
It is estimated that during the year 2 0 1 2 , about 1 4 4 , 9 3 7
breast cancer has been observed in women exposed to
new cases of breast cancer in women occurred in India,
radiation. (ii) Oral contraceptives : Oral contraceptive
which accounts for 27 .0 per cent of all malignant cases (an
appears to have little overall effect on breast cancer,
incidence rate of 2 5 . 8 per lac population). About 70,218
although prolonged use of oral pills before the first
women died of this cancer (mortality of 2 1 . 5 per cent of all
pregnancy or before the age of 25 may increase the risk in
cancer cases), mortality rate being 1 2 . 7 per lac population,
younger women (44).
ranking number one killer in women (6).
PREVENTION
RISK FACTORS
The established risk factors of breast cancer include the a. PRIMARY PREVENTION
following:
Current knowledge of the aetiology of breast cancer (35)
(a) AGE : Breast cancer is uncommon below the age of offers little prospect of primary prevention. However, the
35, the incidence increasing rapidly between the ages of 35 aim should be towards elimination of risk factors discussed
and 50. A slight bimodal trend in the age distribution has above and promotion of cancer education. The average age
been observed (37) with a dip in incidence at the time of at menarche can be increased through a reduction in
menopause. A secondary rise in frequency often occurs after childhood obesity, and an increase in strenuous physical
breast cancer appears to be different (39). Breast screening leads to early diagnosis of breast cancer,
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which in turn influences treatment and, hopefully, mortality. lung cancer is at present increasing more in females than in
No major improvement in survival rates has yet been cause of lung cancer in the 1920s. Subsequent studies
shown by current treatment modalities. Some cases progress proved the causal relationship between cigarette smoking
rapidly even if diagnosed at an apparently early stage, and lung cancer. Two studies in India showed that the lung
others surviving for 20 years even after metastatic spread. cancer risk for cigarette smokers is 8 . 6 times the risk for non
However, in general, the removal of the tumour early is smokers (50, 5 1 ) . The risk is strongly related to the number
more likely to be curative than removal at a later stage (29). of cigarettes smoked, the age of starting to smoke and
Lung cancer has been known in industrial workers from developing lung cancer. It has been calculated that in
the late 19th century. It came into prominence as a public countries where smoking has been a widespread habit, it is
health problem in the Western world in 1930s - at first in responsible for 90 per cent of lung cancer deaths (52). The
men, and later (in 1960s) among women (46), and has strongest evidence that cigarette smoking is responsible for
followed the increasing adoption of cigarette smoking first lung cancer is the incidence reduction that occurs after
by men and later by women. According to WHO reports, cessation of smoking. This has been convincingly
between 1960 and 1 9 8 0 , t h e death rate due to lung cancer demonstrated in a 20-year prospective study on male
increased by 76 per cent in men and by 135 per cent in British doctors (53).
women (47, 27). In countries where cigarette smoking has
The most noxious components of tobacco smoke are tar,
only recently begun to be widely adopted, lung cancer
carbon monoxide and nicotine. The carcinogenic role of tar
deaths still remain low, but it may be expected that they will
is well established. Nicotine and carbon monoxide,
rise soon. In others, such as Poland, where the use of
particularly, contribute to increased risk of cardiovascular
cigarettes began earlier, the rise is already occurring. The
diseases through enhancement of blood coagulation in the
total burden of lung cancer in any country is directly related
vessels, interference with myocardial oxygen delivery, and
to the amount and duration of cigarette smoking.
reduction of the threshold for ventricular fibrillation (8).
Lung cancer has been the most common cancer in the
A study in India has shown that there is no difference
world for several decades, and by 2012, there were an
between the tar and nicotine delivery of the filter and
estimated 1 . 8 2 million new cases, representing 1 3 . 0 % of all
non-filter cigarettes smoked in India, so that a filter gives no
new cancers. It was also the most common cause of death
protection to Indian smokers. The "king-size" filter cigarettes
from cancer, with 1 . 5 8 million deaths ( 1 9 . 4 % of the total).
deliver more tar and nicotine than ordinary cigarettes.
A majority of the cases now occur in the developing
Bidi smoking appears to carry a higher lung cancer risk than
countries (55%). Lung cancer is still the most common
cigarette smoking owing to the higher concentration of
cancer in men worldwide ( 1 6 . 5 % of the total). In females,
carcinogenic hydrocarbons in the smoke (8).
incidence rates are generally lower, but worldwide, lung
cancer is now the fourth most frequent cancer of women (ii) Other factors : Besides cigarette smoking, there are
( 8 . 5 % of all cancers) and the second most common cause of other factors which are implicated in the aetiology of lung
death from cancer (12.8% of the total). The highest cancer. These include air pollution, radioactivity, and
incidence rate is observed in Northern America (where lung occupational exposure to asbestos, arsenic and its
cancer is now the second most frequent cancer in women), compounds, chromates, particles containing polycyclic
and the lowest in Middle Africa (15th most frequent cancer). aromatic hydrocarbons and certain nickel-bearing dusts.
7 0 , 2 7 6 new lung cancer cases of which 5 3 , 7 2 8 were men In lung cancer control, primary prevention is of greatest
and 16,547 women (incidence rate of 6.9 per lac importance. The most promising approach is to control the
population). About 63, 759 persons died of lung cancer "smoking epidemic", because 80 to 90 per cent of all cases
during the same year, of which 48,697 were men and of lung cancer in developed countries are due to smoking of
15,062 women (a mortality rate of 6.3 per lac population). It cigarettes (50). Methods of controlling the smoking epidemic
accounts for 6 . 9 per cent of all malignancies and 9.3 per have been described by the WHO expert committees in their
cent of all deaths due to cancer in the country (6). reports (49, 53). Broadly these methods include :
age of 6 5 . In many industrialized countries, the incidence of d. National and international coordination
CANCER
a. Public information and education met with only limited success. For untreated patients, the
b . Legislative and restrictive measures estimated to have occurred in 2012 (6.8% of the total),
places; restriction on smoking in places of work, etc. (52). Stomach cancer is the third leading cause of cancer death
manufacturers or persons trading in cigarettes to display About 63,097 new cases of stomach cancer were
prominently the statutory warning "Cigarette Smoking is estimated to have occurred in India during 2012 (an
Injurious to Health" on all cartons or packets of cigarettes incidence rate of 6.2 cases per lac population)· of these
that are put on sale. Most of the State Governments in India 43,386 were in men and 19,711 in women. About 5 9 , 0 4 1
have promulgated laws prohibiting smoking in closed areas, persons died of stomach cancer (mortality rate of 5. 7 per lac
e . g . , cinemas, buses, educational institutions, and hospitals. population) of which 40,721 were men and 18,320
information on specific smoking cessation methods such as Stomach cancer cases have a generally poor survival
smoking cessation clinics, nicotine substitutes, hypnosis, etc. prognosis, averaging no more than 20% survival after five
References
2. SECONDARY PREVENTION
and appears to have less potential for reducing mortality 4. GLOBOCAN 2013, World Fact Sheet, (2013), Section of Cancer
Efforts to find effective treatment for lung cancer have 6. GLOBOCAN 2013, India Fact Sheet, 2013, Section of Cancer